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APPLICATION FOR REFUND OF CONTRIBUTIONS Date of Application ___________________________ TO: BOARD OF TRUSTEES EMPLOYEES RETIREMENT SYSTEM OF THE GOVERNMENT OF THE VIRGIN ISLANDS I hereby request a refund of contributions made by me as a member of the Employees Retirement System of the Government of the Virgin Islands under and in pursuance of the provisions of Title 3 of the Virgin Islands Code. In connection with this request, I, _______________________________________________________________________, declare that I am entitled to such refund by reason of _____________________________________________________. My title is ________________________________________________________________________ at the Department of ____________________________________________ on the island of _________________________________________ effective on _________–_________–_______________. Gender ______________________________________ Tel No. _______________________________________ I further declare that I am not on leave of absence at this time and do not expect to transfer to another department covered by the provisions of the said System; that I am not employed in any capacity by the Government of the Virgin Islands and that I do not have a right to appointment at this time to any position in the service of the Government. In consideration of the amount payable to me as refund, I do forfeit and relinquish all accrued rights in the Retirement System including all accumulated creditable service. DO YOU HAVE A LOAN WITH THE RETIREMENT SYSTEM? Personal Loan Yes K No K Mortgage Loan Yes K No K Land Loan Yes K No K Auto Loan Yes K No K I hereby represent that I have no other claims against the Employees Retirement System of the Government of the Virgin Islands except as herein stated, and the acceptance of this refund by me shall operate as a release of any claims which I may have against the said System of all kinds and my own free will and accord. I further declare that I have read and understand this application and am signing the same of my own free will and accord. Date of Birth __________–_________–_______________ SSN __________________________________________ Physical Address __________________________________ Mailing Address ________________________________ _________________________________________________ ______________________________________________ _________________________________________________ ______________________________________________ Note: Refunds cannot be processed until six weeks after the end of the Quarter in which the applicant receives his final regular salary payment. A refund is payable to members only upon withdrawal from service, which means under the Act "complete severance of employment of a member as an employee of the employer, by resignation, discharge, dismissal or death" or in the case of erroneous deductions. Continued on the reverse side (Print Name) (Signature of Member) (Witness) (Resignation or Dismissal) m m d d y y y y m m d d y y y y City State Zip City State Zip GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497 GERS-BEN104 REV 06 (Select a value) (Select a value) (Select a value) OATH I , ______________________________________________, of _______________________________________________ (Signature of Applicant) (Address) the person above named, having been duly sworn, do, under oath, depose and say: That I am the person who made the foregoing statements; that I have carefully read the above questions and the answers thereto, and understand the same; that each and every one of such answers is full, complete and true, and no material fact has been concealed or omitted therefrom, and that said answers are made for presentation to the Board of Trustees of the Employees Retirement System of the Government of the Virgin Islands in making claim for a survivors retirement annuity that may be payable to me by said System. ________________________________________________ (Name of Applicant) xxxxxxxxxxxxxxxxx Territory of the U.S. Virgin Islands } District of } ss: On this ____________day of__________________________ , before me personally appeared ________________________________, known to be the individual whose named is subscribed in the foregoing instrument and acknowledge that ________________________ executed the same as __________________________ free and voluntary act. ____________________________________________________ Notary Public Commission Expires ___________________________________ GERS-BEN104 REV 06